REGARDING USE OF TELEMEDICINE SERVICES
The purpose of this form is to provide you with information about telemedicine and to obtain your informed consent to participate in a telemedicine health service as part of your medical care.
NATURE OF TELEMEDICINE
Telemedicine involves the use of electronic communications to enable a health care provider and a patient at different locations to share medical information for the purpose of evaluation, diagnosis, consultation, or treatment of the patient. The delivery of healthcare via telemedicine allows the patient and provider to establish a relationship, much as they would during a traditional face-to-face appointment. For example, your telemedicine encounter may include interaction through and with the use of the internet, recorded audio communications, physical examinations, medical imaging, medical tests, and diagnoses, as well as related technologies known as “store-and- forward.”
The benefits of telemedicine include improved access to medical services and care, including the expertise of specialists and consultants that may not otherwise be available to you. Telemedicine also permits increased efficiency in evaluations, diagnoses, consultations, and treatment.
The potential risks associated with the use of telemedicine are rare, but include delays in medical evaluation and treatment due to equipment failures or information transmission deficiencies (such as poor image resolution); breach of privacy of protected health information due to security breaches or failures; and adverse drug interactions, allergic reactions, complications, or other errors due to patient’s failure to provide complete medical information or records. Missed or inaccurate diagnosis are risks in any healthcare setting generally but these risks may be amplified in a telemedicine setting due to the inability of the treating practitioner to do an in person physical exam.
POTENTIAL ADVERSE REACTIONS
The practitioners at Hemlock Medical will be providing you with a prescription for either Acyclovir or Valacyclovir. Potential adverse reactions of the medications prescribed by Hemlock Medical include but are not limited to:
Hallucinations, psychosis, delirium, aggressive behavior, encephalopathy, seizures, coma, leukopenia, thrombocytopenia, angioedema, anaphylaxis, erythema multiforme, Steven Johnson syndrome, toxic epidermal necrolysis, hepatitis, tissue necrosis, renal failure, hemolytic uremic syndrome, TTP, nausea, vomiting, headache, diarrhea, malaise, dizziness, arthralgia, rash, lethargy, confusion, agitation, BUN and Cr elevated, photosensitivity, dysmenorrhea, depression, elevation of liver enzymes, fatigue.
Please note that if you are taking any additional medications there may be the potential for drug interactions between your existing medications and the medications prescribed. By signing this informed consent form you are agreeing to provide an accurate list of all prescription and over the counter medications you are currently taking or have taken within the past month. While the physicians, physicians assistants, and nurse practitioners prescribing you these medications will check for potential medications interactions before prescribing Acyclovir or Valacyclovir, Hemlock Medical and its employed healthcare providers are not liable for any harm or damages caused by an adverse reaction caused by these medications directly or any associated medication interactions.
PACKAGING AND FULFILLMENT RESTRICTIONS
The medication, if approved, will be shipped from one of our partner pharmacies below in non-child-resistant packaging and must be kept out of the reach of children.
PostMeds, Inc. 3121 Diablo Ave, Hayward, CA 94545 650.353.5495
Curexa 3007 Ocean Heights Ave, Egg Harbor Township, NJ 08234 855.927.0390
YOU AGREE TO INDEMNIFY AND HOLD HARMLESS Hemlock Medical, ITS EMPLOYEES, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO HEMLOCK MEDICAL NEGLIGENCE.
Alternative methods of care may be available to you, such as in-person services. Your provider will explain any such options to you, and you may choose an alternative at any time.
FOLLOW-UP CARE; EMERGENCY SITUATIONS
In some situations, telemedicine is not an appropriate method of care. If there is an urgent situation, if you have an adverse reaction, if a technical failure prevents you from communicating with your telemedicine provider, or if you believe telemedicine will not provide sufficient safety and quality, you should contact Hemlock Medical as indicated below. If the contacts listed below are unavailable, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. If the situation is an emergency, call 911.
Dr. Laura Purdy, MD Board Certification: Family Medicine NPI: 1093058463 Email: Laura.Purdy@hellowisp.com AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Dr. Marc Serota, MD Board Certification: Dermatology, Allergy/Asthma/Immunology NPI: 1740410463 Email: Marc.Serota@hellowisp.com AL AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA MD MI MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VA WA WV WI WY
Dr. Sara Medunick, DO Board Certification: Family Medicine NPI: 1497742761 Email: Sara.Medunick@hellowisp.com CA CO KY MO NJ NY VA WI
For a list of providers' state licenses, please see Provider Credentials.
YOUR PRIVACY RIGHTS
Hemlock Medical uses network and software security protocols to protect the confidentiality of your patient health information, including for example your medical record, EMR, imaging, and personal financial data. These protocols are designed to safeguard the data and to ensure its integrity against corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in Hemlock Medical Pages.
By signing this form, I understand the following
Telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider. I understand that I need to provide a full and accurate medical history, including any pre-existing conditions, to my telemedicine provider so that my provider can accurately determine what services I need. I further understand that my provider will determine whether telemedicine is appropriate for me at this time, based on the condition being diagnosed and/or treated. I understand that I may benefit from telemedicine, but that results cannot be guaranteed. My provider will inform me who will be present at the provider’s location during the telemedicine service and I have the right to exclude anyone from being present, if I so choose. I further understand that I have the right to object to the use of a telemedicine service without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled. If there are costs to me associated with my telemedicine encounter, a health care professional will discuss those costs with me prior to the start of my session. Further, I understand and agree that I must pay the full amount of the costs associated with this telemedicine service, including any prescription I may receive, and I will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine and I agree that Hemlock Medical may provide my confidential personal health information to other medical providers who may be located in other areas, including on rare occasions to providers outside the State, as necessary. I further understand that my medication, if approved, will not be shipped in child-resistant packaging and that I must keep it out of the reach of children. I have the right to inspect and obtain copies of all information received and recorded during any telemedicine session, subject to the policies of the physicians, physician assistants, nurse practitioners and facilities involved in my care. I may be charged a fee for copies of my records in accordance with applicable State rules. I have read and understand the information above and all of my questions have been answered to my satisfaction.
I consent to a Hemlock Medical physician, physician assistant, or nurse practitioner to provide services to me via telemedicine.
By clicking "I Agree" below, I understand and consent to the foregoing acknowledgments and disclosures including Hemlock Medical Terms of Service and Notice of Privacy Practices. Further, for purposes of this informed consent, MY ACT OF CHECKING The "I Agree" BOX SHALL CONSTITUTE AND IS MY ELECTRONIC SIGNATURE.